Referral Claim Your Reward Fill out the form below to receive your exclusive reward. Submitter Full Name* Submitter Email* Submitter Phone Number* Submitter Company (optional) Permission Confirmation Checkbox I have obtained permission from the property owner/manager for Chargox placement. Enter the full street address of the proposed location. Specify the city where the property is located. Property Province/State Select or enter the province/state (e.g., Manitoba).Manitoba Property Postal Code Business Name Business Type Select typeRetailOfficeGymMallRestaurantOther Estimated Daily Foot Traffic Power Outlet Details Property Owner/Manager Full Name Owner/Manager Phone Number Owner/Manager Email Owner/Manager Relationship to Property RoleOwnerManagerLesseeOther (specify) Preferred Contact Method Best way to reachPhoneEmailIn-person Reference/Confirmation Number Exact Placement Location Description Available Space Dimensions (optional) Site Photos Upload (Upload 1-5 photos of the proposed placement area (max 10MB each)) Upload photos of the electrical outlet and nearby area. Machine Quantity Number of ChargoX machines proposed: 1, 2, More.12More Accessibility Notes Restrictions Notes Agreement Terms Notes Floor Plan Upload (optional) Marketing Opt-in Checkbox Check for promotional updates on Chargox opportunities.
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